Management of Increased ICP - Pediatric Critical Care Education

Report
Pediatric Septic Shock
PICU Resident Talk
Stanford School of Medicine
Pediatric Critical Care Medicine
June 2010
Learning Objectives
After this lesson, the participant will be able to:
• Distinguish the terms SIRS, sepsis & septic
shock.
• List physiologic changes that occur in sepsis
and explain how each factor affects O2
demand/ delivery.
• Understand the rationale for goal directed
therapy in septic shock
Septic Shock
Systemic inflammatory response syndrome (SIRS)- The
presence of at least two of the following one of which must be abnormal
temperature or leukocyte count.
- Temperature. >38 or <36.
- Tachycardia
- Tachypnea
- Leukocyte count increased or decreased or > 10% bands.
Sepsis- SIRS in the presence of infection.
Severe sepsis-
Sepsis plus end organ dysfunction i.e. ARDS, renal
dysfunction, coagulopathy.
Septic shock- Sepsis plush cardiovascular organ dysfunction.
Goldstein et al. Pediatr Crit Care Med 2005
American College of Critical Care Medicine
Hemodynamic Definitions of Shock
Brierley, Carcillo et al. Pediatr Crit Care Med 2009
Sepsis leads to microvascular occlusion,
vascular instability,
and organ failure
through complex
interactions between
pathogens, immune
cells, and the
endothelium.
Cohen, Nature 2002
The predominant cause of
mortality in adult sepsis is
vasomotor paralysis.
Parker, et al. Crit Care Med. 1987
Contrary to adults low cardiac output not
low SVR is associated with mortality in
septic shock in children.
Pollack et al. Crit Care Med 1984, 1985
Early Intervention in the treatment of septic
shock is vital: The first hour in the ED
Maintain and
restore
airway,
oxygenation,
and ventilaton
Monitoring
Therapeutic
endpoints
Therapeutic Endpoints
Fluid Resuscitation
& Hemodynamic Support
• Threshold heart-rates
• Age appropriate perfusion
pressure
• UOP > 1 cc/kg/hr
• CI> 3.3 and less than 6 L/min/m2
• Scvo2 >70%
• Normal perfusion
• CRT< 2 seconds
• Normal INR, anion gap, lactate
Hemodynamic Support
In the fluid
refractory
patient begin a
peripheral
inotrope while
establishing
central access.
If dopamine
refractory start
epinephrine in
cold shock.
If dopamine
refractory start
norepinephrine
in warm shock.
Goal is normal
perfusion and
blood pressure.
Consider CI, BP, and SVR when implementing CV
support.
Low CI
Normal blood
pressure
High SVR
Low CI,
Low blood pressure
Low SVR
Afterload reduction
may improve blood
flow by increasing
ventricular
emptying.
(Beware of Cyanide
toxicity)
Norepinephrine can
be added to
epinephrine to
increase DBP and SVR.
Once adequate BP is
reached dobutamine,
or Milrinone can be
added to improve CI
and Scvo2.
Norepinephrine,
fluid
If shock persists
consider Vasopressin
Nitroprusside
Milrinone.
High CI
Low or normal
Blood Pressure
Low SVR
Pediatric Septic Shock Algorithm
Brierley, Carcillo et al. Pediatr Crit Care Med 2009
Refractory Shock??
Mechanical Problem?
Pericardial effusion
Pneumothorax
Increased abdominal
Pressure.
Necrotic tissue.
Ongoing blood loss
Immune?
Excessive immunosuppression
Uncontrolled infection
? ?
? ?
Endocrine?
Hypothyroid
Hypoadrenal
Early Goal directed therapy
resulted in a 40% reduction in
mortality compared to control
in adult patients with septic
shock.
Rivers et al. NEJM 2001
Early Shock REVERSAL resulted in 96% survival versus 63% survival
among patients who remained in persistent shock state
Han, Y. Y. et al. Pediatrics 2003
Goal directed therapy causes a significant reduction in
28 day mortality in children with septic shock
Oliveira et al. Intensive care med 2008
Summary of Key Points
• Early goal directed therapy can improve
outcomes in septic shock
• Pediatric septic shock is different from adult
septic shock

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